Attention: All Providers

NCTracks Updates

EPSDT Policy Update

Note: Behavioral Health and Waiver services are not impacted by this change. Local Management Entities - Managed Care Organizations (LME-MCO) and Value Options continue to review and authorize prior approvals for these service areas.

Effective with dates of service on or after April 1, 2014, Computer Sciences Corporation (CSC) assumed responsibility for processing prior approval (PA) requests for beneficiaries under 21 years of age who received services through Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)* program in the following service areas:

Dental

Orthodontic

Durable Medical Equipment (DME) including Orthotics and Prosthetics

Medical/Surgical

Visual Aids/Optical

Hearing Aid

Pharmacy

EPSDT prior approval requests were previously processed by the N.C. Division of Medical Assistance (DMA). PA requests with dates of service prior to April 1, 2014 are being processed by DMA.

This Non-Covered Services form must be submitted / uploaded along with supporting documentation via NCTracks. Do not submit the form by itself. For example, if the non-covered service needed is a DME service, follow the normal process for requesting a DME Prior Approval and include the completed Non-Covered Services Form along with supporting documentation.

Note: The previous DMA version of this form is no longer available.

* Federal Medicaid law at 42 U.S.C.§ 1396d(r) [1905(r) of the Social Security Act] requires state Medicaid programs to provide Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for recipients under 21 years of age. Within the scope of EPSDT benefits under the federal Medicaid law, states are required to cover any service that is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition identified by screening,” whether or not the service is covered under the North Carolina State Medicaid Plan. The services covered under EPSDT are limited to those within the scope of the category of services listed in the federal law at 42 U.S.C. § 1396d (a) [1905(a) of the Social Security Act].

The state has authorized providers to resubmit sterilization consent forms that have been permanently denied for illegible signatures and/or an initial used for the first name of the recipient, interpreter, witness, or physician, if the Recipient/Witness signature date is prior to July 1, 2013.

Providers will need to print their full name under their signature, then resubmit the consent form by mailing it to CSC, P.O. Box 30968, Raleigh, NC 27622.

Requesting Retroactive Approval for Long Term Care (LTC)

A new How to Request Retroactive Approval for LTC, is now available. The guide explains both:

How to submit a request for Long Term Care (LTC) Retroactive approval on the initial Prior Approval (PA) request

How to submit a request when there is an approved Long Term Care PA in NCTracks and the provider needs PA approval for retroactive dates

All Pregnancy Medical Home claims need to include the modifier “AF” with the procedure code submitted, regardless of the dates of service. The “AF” modifier will enable the provider to be paid at the rate previously received in the legacy system.

NCTracks supports all three types of Pregnancy Medical Home claims that receive higher reimbursement, including the pregnancy risk screening, delivery, and postpartum plan. Providers who previously filed Pregnancy Medical Home claims that were denied or pended for Edit 353 (rate not found) need to re-submit the claims using the “AF” modifier.

Dental Providers - Use the Correct PA Form

Some dental and orthodontic providers have been submitting PA requests on the DMA 372-118 form (NC DMA Request for Prior Approval). This form is for medical providers. Since NCTracks launched on July 1, 2013, there has been no change for dental or orthodontic providers submitting PA requests by mail or fax. Dental and orthodontic providers are still required to use the 2006 American Dental Association (ADA) form.

If a dental or orthodontic PA request is sent to NCTracks using the DMA 372-118 form for medical providers, the PA will be routed to medical PA review. This will delay the review of the PA.

Providers should use the web portal to submit PAs and additional information rather than mailing or faxing. However, if submitting a paper form, be sure to submit dental and orthodontic paper PA on the 2006 ADA form.

Attention: All Providers

Receiving Email Alerts Through NCTracks

Note to Providers: This article was originally published in September 2013.

Providers can subscribe to email alerts through the NCTracks Provider Portal at www.nctracks.nc.gov/. Alerts are sent when there is important information to share between monthly issues of the Medicaid Provider Bulletin. Past email alerts have included information on such topics as:

Common Billing Errors

Enhanced Payments under the Affordable Care Act

HIPAA/ICD-10

Medicare Crossover Claims

Prior Approval

Updating and Amending Applications

Using Skillport

To receive email alerts and other communications from NCTracks, visit https://www.nctracks.nc.gov/content/public/providers/provider-communications.html. Use the link “Click here to join mailing list” under the heading “Sign Up for NCTracks Communications” in the upper right corner of the page. Providers who currently receive email alerts will continue to receive them through NCTracks. No other actions are required.

Email addresses will never be shared, sold or used for any purpose other than Medicaid and N.C. Health Choice email alerts and NCTracks communications.

Attention: All Providers

Update: NC Medicaid Provider Enrollment, Screening and Training

Federal and state regulations which require certain providers to undergo supplemental screenings based on their risk category for fraud, waste and abuse have been updated.

Historical Requirements

Beginning October 1, 2012, the N.C. Division of Medical Assistance (DMA) implemented Federal regulations 42 CFR 455.410 and 455.450. These regulations – which are still in effect – establish three categories for N.C. Medicaid and N.C. Health Choice (NCHC) provider types in order to assess their risk of fraud, waste, and abuse.

Low,

Moderate

High.

It further requires that DMA conduct onsite screenings of all newly enrolling, re-enrolling or re-validating providers who fall into the “moderate” or “high” risk categories.

Additionally, Federal Code of Regulations at 42 C.F.R. 455.432 grants state Medicaid agencies the authority to conduct POST-enrollment site visits. Public Consulting Group (PCG) will continue to conduct site visits on behalf of DMA, including visits to recently enrolled providers who are considered moderate- or high-risk but have not yet completed screening requirements.

PCG will schedule and announce ALL pre- and post-enrollment related site visits.

In order to be successful, providers who are enrolled and delivering Medicaid services but have not completed the onsite visit requirements are strongly encouraged to familiarize themselves with the following information prior to being contacted by PCG:

The most significant change in this session law as it relates to enrollment screening requirements is the removal of Dentists and Orthodontists from the moderate-risk category and placing them in the limited risk category. A full text of the amended state regulations related to onsite screenings can be found at http://www.ncga.state.nc.us/Sessions/2013/Bills/House/PDF/H399v10.pdf

Attention: All Providers

Procedure Code Update: Laminoplasty

Effective June 1, 2014 Medicaid will cover:

Procedure Code 63050: Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; and

Procedure Code 63051: Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices (e.g., wire, suture, mini-plates), when performed.

These procedures will require prior approval which can be submitted through NCTracks.

Attention: Behavioral Health Providers

DSM-5 Implementation

The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released in May 2013. The N.C. Department of Health and Human Services (DHHS) will fully implement DSM-5 coding requirement effective August 1, 2014.

Thus, DSM-5 codes will be required for all dates of services beginning August 1, 2014 and going forward.

The August 1, 2014 implementation gives clinical professionals additional time to learn the right diagnostic codes for service authorization requests. This change will apply to both Division of Mental Health/Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) and Division of Medical Assistance (DMA) behavioral health services covered by the Local Management Entities-Managed Care Organizations (LME -MCOs), as well as behavioral health services authorized by Value Options and paid by NCTracks for N. C. Health Choice beneficiaries and Medicaid beneficiaries 3 years old or younger.

Attention: ‘Be Smart’ Family Planning Waiver Providers

Update: The ‘Be Smart’ Waiver Conversion to a State Plan Amendment has been Delayed

The N.C. Division of Medical Assistance (DMA) has submitted a request to the Centers for Medicare & Medicaid Services (CMS) to convert the “Be Smart” Family Planning Waiver program to an amendment to the Medicaid State Plan. The “Be Smart” Family Planning Waiver has been extended through September 30, 2014. The State Plan Amendment will be submitted to and approved by CMS prior to that date. Despite the delay, the Family Planning Waiver will continue to operate with no interruption in service to its beneficiaries.

Place of Service Billing for Core Services

Core services provided by a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) should be billed with “POS code 50 (Federally Qualified Health Center)” for the FQHC and “POS code 72 (Rural Health Center)” for the RHC. Effective with date of service July 1, 2014, system changes will be made that will allow only POS code 50 (for FQHC) and POS code 72 (for RHC) to be submitted on the claim for payment of core services.

Attention: Hospitals and OB/GYN Providers

Presumptive Eligibility

State approved medical providers may screen patients for eligibility in Medicaid for Pregnant Women (MPW). When presumptively eligible, a woman may receive prenatal ambulatory services until the end of the month following the date of her Medicaid application. This allows beneficiaries adequate time to apply for Medicaid at the Department of Social Services (DSS) or online at www.ePASS.nc.gov.

If the pregnant woman fails to apply for Medicaid or Work First within this time period, she is eligible for limited Medicaid services until the last calendar day of the month following the month she is determined presumptively eligible. For example, if the woman receives medical services under presumptive eligibility in April, she has until May 31 to apply for Medicaid. If the pregnant woman applies for Medicaid within this time frame, she remains presumptively eligible for Medicaid until the county DSS office makes a determination on her application.

During the presumptive eligibility period, Medicaid will cover only ambulatory prenatal services provided by a Medicaid enrolled provider. This includes prescriptions.

Resubmitting Denied Claims

If pregnancy-related claims are submitted before a (i) beneficiary applies or (ii) determination has been made by DSS, the claims will deny with Edit/Explanation of Benefit (EOB) Code 00268/00139. The provider can submit a paper claim with a copy of the Remittance Status displaying the denial code to:

The DMA Claims Analysis Unit will research the eligibility files for DSS approval. If approval is found, the Claims Analyst will special batch the claim and override presumptive denial. If no approval is found, the claim will be returned to the provider with an explanation.

Undocumented Individuals

Undocumented individuals requesting Medicaid coverage for medical emergencies must meet categorical and financial eligibility requirements, including state residency. In addition, the medical services rendered must meet the federal definition of “emergency services.” The definition of an emergency medical service includes vaginal or C-section delivery. Undocumented individuals are only authorized for Medicaid services for the actual days they receive an emergency medical service. For all other emergency services, including miscarriages and other pregnancy terminations, the N.C. Division of Medical Assistance (DMA) determines the eligibility coverage.

*Note: Sterilizations do not meet the definition of “emergency services” and are not reimbursed for undocumented individuals.

Attention: Pharmacists and Prescribers

NC Medicaid and N.C. Health Choice Preferred Drug List Changes

Effective with an estimated date of service of May 17, 2014, the N.C. Division of Medical Assistance (DMA) will make changes to the N.C. Medicaid and N.C. Health Choice Preferred Drug List (PDL). Below are highlights of some of the changes that will occur:

The prior authorization criteria will be removed from the second generation anti-convulsant class

The use of only Spiriva® in the COPD class will be required before moving to a non-preferred agent

Adderall XR and Adderall generics will be removed from the PDL entirely. Prior authorization will be required for these generic products.

Attention: Pharmacists and Prescribers

Makena Will Be Available June 1, 2014 Via Point of Sale

Makena is still available through the Physicians Drug Program (PDP) at a rate of $2.87 per milligram. In addition, the N.C. Division of Medical Assistance (DMA) also covers the compounded product, 17P, through the PDP program. The compounding product may be unavailable soon and, in order to prevent any barrier in obtaining the product, DMA has chosen to allow Makena to be dispensed at point-of-sale (POS) starting June 1, 2014. DMA may impose a prior authorization requirement in the near future.

Makena may have limited distribution. Visit the manufacturer (Ther-Rx Corp.) website at www.ther-rx.com/, or call the company at 1-877-567-7676, to learn more about obtaining Makena through the PDP program or through POS.

Proposed Clinical Coverage Policies

In accordance with NCGS §108A-54.2, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the Proposed Clinical Coverage Policies web page at www.ncdhhs.gov/dma/mpproposed/. Providers without Internet access can submit written comments to:

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is substantively revised as a result of the initial comment period. If the adoption of a new or amended medical coverage policy is necessitated by an act of the General Assembly or a change in federal law, then the 45 and 15-day time periods shall instead be 30 and 10-day time periods.

2014 Checkwrite Schedule

Month

Checkwrite Cycle Cutoff Date

Checkwrite Date

EFT Effective Date

May

5/01/2014

5/06/2014

5/07/2014

5/08/2014

5/13/2014

5/14/2014

5/15/2014

5/20/2014

5/21/2014

5/22/2014

5/28/2014

5/29/2014

5/29/2014

6/03/2014

6/04/2014

June

6/05/2014

6/10/2014

6/11/2014

6/12/2014

6/17/2014

6/18/2014

6/19/2014

6/24/2014

6/25/2014

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.